Provider Demographics
NPI:1205547791
Name:HARRIS, DEQUINTE
Entity type:Individual
Prefix:
First Name:DEQUINTE
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23702-1852
Mailing Address - Country:US
Mailing Address - Phone:757-372-2542
Mailing Address - Fax:
Practice Address - Street 1:112 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23702-1852
Practice Address - Country:US
Practice Address - Phone:757-372-2542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT61557011Medicaid